Dr Tom Ratcliffe

General Practice at the Deep End Yorkshire and Humber at 5 years

A personal reflection by Dr Tom Ratcliffe, GP

I had been working as a GP in Airedale, just west of Bradford, for around 2 years when I got involved with setting up GP at the Deep End Yorkshire and Humber. Like many parts of the country, Airedale is an area of socioeconomic extremes. On one edge of our patch lies Skipton and Craven, reportedly the happiest place in the UK, and on another, Wharfedale, which hosts some of the most expensive housing in Northern England. I had completed most of my GP training in Keighley, a town closer to Bradford with a much more mixed socioeconomic outlook, and eventually took up a permanent position at Holycroft Surgery, located within one of the most deprived council wards in the UK.

As with many areas, travel across the Airedale locality and life experience, along with pretty much every other indicator of health and wellbeing, varies dramatically – an 8 mile journey can encompass a 10 year difference in like expectancy at birth for local inhabitants. However, it was not the abstract idea of health inequality and these statistical variations that got me interested in the Deep End movement. Rather, it was the shared experience of healthcare professionals working in areas of socioeconomic deprivation.

It was immediately apparent that our patients came with layers of problems and issues born out of a lifetime of disadvantage. Even something simple like a rotator cuff strain was rarely just a rotator cuff strain. How would you help get this better when the patient was working 12-14 hours a day as a carer on a zero-hours contract doing manual handling all day, did not have the money to take time off work, had the recovery rate of someone 20 years older due to a lifetime of stress and childhood trauma and struggled to remain motived to exercise due to depression and having to look after her alcoholic partner?

It was also a period when I’d watched a procession of brilliant GPs move out of my practice in Keighley to work in leafier neighbouring areas, emigrate or become unwell and retire. One GP remarked to me: “I spend a lot of my time doing social work and I just can’t carry on being here until 8 or 9pm every day trying sort peoples’ lives out. It’s making me ill”. It was around this time I read about GPs at the Deep End in Scotland. Graham Watt’s swimming pool analogy really struck a chord.

Reading through the Deep End group’s short papers, made me realise there were others out there grappling with all of the problems I was seeing and that there was this vast well of wisdom that I, a relatively newcomer, could tap into. It was also inspiring and energising to see this tough and vital work given recognition through academic and Government institutions.

From October 2015, we hosted a series of increasingly well attended meetings under the GP at the Deep End banner. We decided that the areas we needed to address were Workforce, Advocacy (for GPs and people in the communities where they worked), Education and Research.

Things developed quickly. As well as the accumulated wisdom our of colleagues in Scotland and figures such as Julian Tudor-Hart, we met amazing people like John Patterson, Laura Nielsen and the Shared Health, Focussed Care and Citadel Healthcare teams from Greater Manchester, who had set up primary care with the aim of tackling health inequalities at its heart and transformed lives across their communities in Oldham and beyond. Irish GP Austin O’Carroll inspired us all with the amazing North Dublin City Training Programme, which trains GPs to work with people living in areas of deprivation and with marginalised groups. Jonathon Tomlinson from Hackney in East London helped us learn about the role of trauma in peoples’ lives and how GPs could help through “trauma informed care”. Greg Fell, now Director of Public Health in Sheffield, has helped us focus on the role of public health in primary care and the evidence base for addressing health inequalities as GPs. Perhaps most importantly, GPs in working in Yorkshire and Humber’s major cities got to meet each other and share stories of how they’d helped patients living in communities with huge and, at times, seemingly insoluble challenges.

We set up with award-winning Fair Health website to share this collected knowledge and experience with GP trainees across the region and, now, nationally and internationally through e-learning modules, blogs and podcasts. We have “Trailblazer” training programmes specifically focussed on deprivation for GP trainees and new qualified First5 GPs. We have hosted a series of brilliant and motivated “health equity leadership” fellows in the School of Primary Care who have helped ensure every new GP in Yorkshire and Humber has received specific training around health equity and spent time out of the GP surgery in their communities.

In undergraduate education, Ben Jackson at the University of Sheffield has set up a programme of community based medical education around health inequalities. Liz Walton has set up a research network across practices in the city’s most deprived communities, increasing patient participation in designing and enrolling in medical research, and also helped write up our experiences in the BJGP and other journals.

Increasingly, our Deep End colleagues are taking on senior leadership positions or becoming involved in advocating for change across the NHS in Yorkshire and Humber. We have been lucky enough to contribute to two books: Tackling Causes and Consequences of Health Inequalities; The Exceptional Potential of General Practice, which set out approaches to workforce development and curriculum delivery.

Yorkshire and Humber GPs at the Deep End cannot and would not want to take credit for all this amazing work. But it has provided a rallying point for enthusiastic GPs. We hope it has provided some inspiration and helped us learn from each other. Perhaps most importantly, the movement has raised the profile of some the most challenging and important work in the NHS and made those people doing it feel a little less alone and a little more supported.

A summary of our work over the last 5 years can be found below.